EM Quick Hits 4 Acetaminophen Overdose & Warfarin Interaction, Dental Infections, MTP RABT Score, Statins for STEMI, Cricothyrotomy Tips

Topics in this EM Quick Hits podcast David Juurlink on acetaminophen and warfarin drug interaction (00:32) Hans Rosenberg on management of dental infections (08:03) Emily Austin on dialysis in massive acetaminophen overdose (14:46) Andrew Petrosoniak MTP decisions and the RABT score in trauma (20:05) Joel Yaphe on statins for STEMI from Whistler's Update in EM Conference (26:49) George Kovacs on how to maximize success of a cricothyrotomy from EM Cases Course 2019 (31:25) Podcast production, editing and sound design by Anton Helman Podcast content, written summary & blog post by Emily Austin, Anton Helman, Andrew Petrosoniak and Hans Rosenberg, edited by Anton Helman Cite this podcast as: Helman, A. Juurlink, D. Rosenberg, H. Austin, E. Petrosoniak, A. Yaphe J. Kovacs, G. EM Quick Hits 4 - Acetaminophen and Warfarin Interaction, Dental Infections, MTP Prediction in Trauma, Massive Acetaminophen Overdose, Statins in STEMI, Cricothyrotomy Tips. Emergency Medicine Cases. May, 2019. https://emergencymedicinecases.com/em-quick-hits-may-2019/. Accessed [date]. Acetaminophen and Warfarin Drug Interaction * Some people who take ≥ 2-3g of acetaminophen daily will produce enough NAPQI, a toxic byproduct that will interfere with the gamacarboxylase enzyme that requires Vitamin K as a co-factor, causing the INR to reach dangerous levels. * A small double blind RCT from 2006 patients on stable oral anticoagulant therapy with warfarin for at least 1 month were randomized to receive placebo or acetaminophen 1g four times daily for 14 days. Mean INR rose rapidly after the start of acetaminophen and the INR values reached a mean maximum of 3.45 with acetaminophen versus 2.67 with placebo. While this may be considered a small increase, some patients, for unexplained reasons, will have an increase far greater. * Think twice about prescribing acetaminophen or any product containing acetaminophen to patients taking warfarin; and for any patient who presents with bleeding while taking warfarin, ask about acetaminophen use. Expand to view reference list * Mahé I, Bertrand N, Drouet L, et al. Interaction between paracetamol and warfarin in patients: a double-blind, placebo-controlled, randomized study. Haematologica.2006;91(12):1621–7. * Caldeira D, Costa J, Barra M, Pinto FJ, Ferreira JJ. How safe is acetaminophen use in patients treated with vitamin K antagonists? A systematic review and meta-analysis. Thromb Res. 2015;135(1):58-61. * Lopes RD, Horowitz JD, Garcia DA, Crowther MA, Hylek EM. Warfarin and acetaminophen interaction: a summary of the evidence and biologic plausibility. Blood.2011;118(24):6269–73. Dental Infections * Differentiate pulpitis versus a periapical abscesses by considering the duration of the pain and secondary signs such as tooth elevation, swelling, adjacent cellulitis, lymphadenopathy and fever. * The definitive treatment of both pulpitis and periapical abscesses require a dentist. Your role in the ED is to diagnose, treat the pain (avoiding opioids whenever possible) and consider antibiotics based on patient factors, both physiological and social.